Pharmacist Intervention in Electronic Discharge Prescribing in Acutely Ill Patients

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Pharmacist Intervention in Electronic Discharge
Prescribing in Acutely Ill Patients

• Anna Yortt
• John Farrell, Sally Dootson
• Martina Hennessy
• Departments of Pharmacy and Clinical Pharmacology
  
• Royal Free Hospital
• London

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The Changing Face of Acute Medicine

• 4 to 5 p.a. rise in the number of acute medical
  admissions in U.K.
• 44 episodes coded as GIM
• 80-90 are acute
• 26 gt 3 admissions.
• RCP unequivocal support the role of specialist
  MAU Pharmacist

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Medicines Management in AMU ?

• Error rates (discharge
• prescriptions )
• range from 5-37

• 30 involve GIM Physicians, patients at risk
  include
• Those with complex conditions
• Those in the emergency room
• Those looked after by inexperienced doctors
• Older patients

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Royal Free Response

• 2003 Introduction of 32 bedded AMU
• Clinical pharmacy should move towards proactive
  involvement in direct patient care and the
  anticipation of errors
• Audit Commission 2001
• 2004 the Royal Pharmaceutical Society PS (HPG)
  recognised focus has remained on medication
  history and supply (Hosp Pharm 2004 11 72-77)
• Limited data available regarding prescribing
  trends in
• AMU

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Royal Free The Issues

• Poor transfer of discharge information to primary
  care
• Poor quality coding
• Absence of clinical data for screening lack of
  input to the discharge process
• 2004 eTTA system introduced
• Medical discharge summary
• Discharge prescription (TTA)
• TTAs screened by pharmacists with clinical data
  
• Summary faxed to GP, copy to patient notes

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Aims Methods

• AIM to assess discharge prescribing trends in
  acutely ill patients
• To examine value of person specific data in this
  setting
• A live intranet link was established between the
  MAU pharmacist,
• and the eTTA database
• 30 day data analysed with respect to
• Demographics, diagnosis, length of stay,
  prescription items, dispensing time
• Concordance
• Medication error (after screening)
• Medication/ diagnoses discrepancy

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Methods 2

• Random independent data review (gt95 agreement)
• Data analysed non parametrically (population
  skewed by age)
• Post hoc analysis (Dunns)
• Spearman Correlation where appropriate
• Discrepancy drug without a corresponding
  diagnosis
• Error prescription,dose, administration.
• Concordance medication issue referred to in
  summary
• LOS admission discharge on same date - LOS
  1day

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Results Demographics
331 acute patients admitted / 30 days 146
discharged home
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Results 2

• 70 prescribed gt4 medications
• Patients with LOS 1 day (N18) closely reflected
  the mean
• No requirement for antibiotic
• Typical Diagnosis
• Troponin neg ACS, Vomiting/gastritis/ GI bleed x
  1
• 10/18 further follow up arranged
• Patients with LOS gt 5 days older (NS), more
  diagnoses (5.0 vs 3.9 Plt 0.02)
• 11 identified with concordance issues (med
  review clinic)
• 4 error rate compared with 20 previous study
• Time to dispense TTAs increased ( 2.18h to 3.82h
  )

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Antibiotics

• 30 prescribed oral antibiotics at discharge
• Diagnoses
• LRTI-19
• UTI/ Pyelonephritis - 9
• Helicobacter eradication 4
• PUO/ Miscellaneous-7
• RUTI -3
• Cellulitis 2
• Duration of Tx discrepant with antibiotic policy

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Antibiotic Duration vs Length of Stay
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Statins

• gt32 on statin at discharge
• Relationship between statins and prescription
  items
• (7.7 3.0 vs 5.2 2.8 plt 0.001)? reflects
  chronic Dx

41.3
45.7
10.9
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Proton Pump Inhibitors

• 35 overall on PPI
• 43 had no corresponding diagnosis
• GORD, PUD,GI bleed, NSAID induced gastritis
• gt90 no limit to duration of PPI therapy
• Majority 72 of diagnosis/medication discrepancy
  related to PPI
• 24/51 on PPI were also on low dose aspirin
• Potential to highlight this to primary care

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Controversial Issues

• No cox 2 inhibitors
• 9 pts on clopidogrel and aspirin (all on a PPI)
• 5 clopidogrel no aspirin
• Clopidogrel for aspirin intolerance not
  recommended
• NEJM 2005 jan20 352(3) 238-44
• 3 indications clearly appropriate (remainder
  mainly ACS)
• 11/14 troponin results available (10 negative)
• No duration ascribed to any clopidogrel
  prescription

Clopidogrel recommended for patients with ACS
(NST elevation) at gt mod risk (ECG changes/trop
positive) in combination with aspirin for 1yr
only, thereafter to return to low dose aspirin
only NICE 2004
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Conclusions

• Person specific clinical data matched to TTA
• allowed characterization of typical MAU patient
• Reduced the medication error rate
• Improved communication with GP and patient
• Identified patients with medication issues
  facilitating pharmacist-led medication review
  clinic
• Increased dispensing time (temporarily)
• In the future
• - eTTAs facilitate the acquistion of
  quantitative data on the quality of discharge
  prescribing

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Medication Review 2

• Availability of patient specific data facilitates
  a level 3 medication review
• with a full concordant discussion regarding
  medications
• Value of the proximity of review to the acute
  medical event

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Medication Review

• 17 patients were identified for medication review
• Criteria for review
• Concordance issues identified in summary
• Significant changes to medication during
  admission
• NSF Older People (2001) Introduced an NHS target
  for medication reviews
• Review process
• Medicines Management Collaborative
• Structured programme around medicine management
• Room for Review (2002)
• Methods, tools and definitions

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Typical eTTA Medical Summary